OP-ED

Op-Ed: Jump-Starting Health IT – Best $20 Billion You’ll Ever Spend

An Open Letter to President Obama and the Congress

Please accept my heartfelt congratulations for recognizing health information technology (IT) as one of the most promising targets for public investment at this crucial moment.

As a (formerly practicing) doctor, I’d diagnose our economy on the verge of a Code Blue, and our healthcare system with a more chronic but equally threatening condition.  You’ve recognized how these two illnesses interrelate, with spiraling healthcare costs damaging business competitiveness and job losses threatening healthcare coverage.  If I may offer a second opinion, I concur 100% with your decision to apply the chest paddles now, charged with $20 billion of investment.

Now I would like to offer this promise: I and my fellow health IT leaders are passionately committed to ensuring that this treatment not only succeeds, but delivers a substantial positive return far exceeding the amount invested.  How can we be so confident?  Well, even a 1% improvement in the efficiency of our $2.2 trillion healthcare spend would put us in positive payback territory.  But we can do better than that, and here’s why:

Health IT Products are Ready Right Now   I chair a nonprofit organization that tests and certifies health IT products, so I’m very familiar with the state of that industry and the behavior of potential purchasers.  In the past three years, we’ve certified over 160 electronic health record (EHR) products for doctors’ offices, hospitals, emergency departments, and more.  We rigorously check not just what the software can do, but also for interoperability – the ability to share information with other providers — and the security of the systems as well, all against established standards.  Most doctors know they need EHRs and many will respond to an economic push right now.  And the industry supplying those EHRs is a competitive, diverse marketplace that will respond to growing demand with increased capital investment and job growth.We’ve Learned How to Structure Incentives toward the Desired OutcomesNobody is advocating a massive, unqualified handout of dollars to doctors.  Outright grants may be appropriate for providers in rural and underserved areas, and for safety-net clinics, but in other environments financial incentives should be structured as a series of incremental rewards for progressive achievements.  In the private sector, the Bridges to Excellence program sets an excellent example, while the recently launched Medicare EHR Demo provides a public sector prototype.  These programs offer initial incentive payments for purchasing appropriate technology – a certified EHR — then a second round of money when successfully implemented.  Beyond that, bonuses are paid only as the provider demonstrates improvements in quality or efficiency.  Healthcare payment reform and healthcare IT — twins separated at birth – must grow up and mature together to achieve their full potential.  An Investment in Human CapitalEvery experienced IT hand knows technology is just a tool, and returns on IT investment require strong leadership and dedicated change management.  So some of the stimulus funds should be used to develop the skilled workforce needed.  It may be possible to redeploy IT personnel from other industries to lay broadband infrastructure for healthcare, but we’ll also need to boost health IT training programs.  And doctors and nurses being asked to change their habits are best motivated by one of their own – a clinician champion.  There are plenty of clinicians who have successfully led these projects, and we can’t afford to have their experience locked up within their own organizations — let’s find a way to put them on a health IT inspirational speaking circuit.

Empowering PatientsYou’ve also wisely recognized the need to redirect our health efforts toward prevention, helping people make better choices early in life, and eventually reducing the burden of expensive interventions near the end.  To do this, we need to empower citizens with health knowledge, allowing them to make better health choices and to become more discriminating healthcare consumers.  Personal Health Records (PHRs) will emerge as a platform for this new information flow.  The organization I lead is also preparing to certify these PHRs, to ensure they are secure, private, and can exchange information with EHR systems in doctors’ offices and hospitals.  Projects in this field are a promising area for government investment.The Final Frontier: Healthcare ReformYou’ve recognized the need for dramatic improvements in healthcare, but you’ve decided not to attempt a radical rip-and-replace approach.  That’s a wise choice.  In many towns, hospitals themselves are the major source of jobs; a massive disruption could even shut them down and further weaken the economy.  Fortunately, almost every illness of our current model is amenable to improvement with an assist from better information.  With better data on prices charged and quality of care delivered, we can reform payment to reward clinicians for the quality or their work, instead of just for the quantity.  With EHRs that easily intercommunicate, we can reward better teamwork among providers to re-integrate care despite our fragmented healthcare business model.  And with empowered health consumers and an online connection that extends beyond the occasional visit to the doctor, we can motivate healthy lifestyles and prevention, eventually reversing the growing burden of chronic diseases. We’re Charged Up:  Just Push the ButtonFinally, I see that you understand what is needed to revive our economy: an injection of fiscal stimulus, a steady dose of inspirational leadership, and a big response of energy and optimism from the American people.  So you will be pleased to hear that the health IT community is charged up with those qualities right now.  At our organization, just one of several initiatives in health IT, we’ve seen some two hundred unpaid volunteers serve tirelessly for over three years, and they’re ready to do more.Paddles: charged.  Pathway: clear.  Just push the button, and a new vital rhythm in healthcare will begin.    — Mark Leavitt, MD, PhD   Dr. Leavitt is chairman of the Certification Commission for Healthcare Information Technology, a nonprofit organization with the mission of accelerating the adoption of robust, interoperable health IT.

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23 replies »

  1. Dr. Leavitt:
    It’s obvious that YOU don’t use a c-EHR system. This forced HIT use will fail as it is obvious that physicians don’t want to use c-EHRs,don’t want to have e-prescribing and feel that P4P is a waste of their time and efforts to try to see patients to make a living.
    This mandate will only make it more costly to see patients for what? EHR systems have yet to significantly show an increase in quality, decreased errors, and most importantly, a ROI.
    Al Borges, MD

  2. $20 billion on HIT could make a huge difference in healthcare…but only IF it is spent on the right things in the right way. If this spending continues to proliferate disparate EMR systems, that produce unusable data and require herculean efforts to adapt and modfiy (read this as basically all existing systems) – then this will be a gimmicky approach akin to what WellPoiint tried just a few years ago.
    However, properly thought through, looking at organizations that have achieved great succes through HIT and building a firm foundation upon proven medical informatic principles, then this $20 billion could do a world of good.
    As a CIO in an integrated delivery system I have had my eyes opened to see the wisdom and benefit of following proven informatics principles. Although we may not be perfect, our organization has achieved some amazing results by using data and knowledge. HIT will not save healthcare, but as an integral component with operations and organizational leadership, HIT can help in this tansformation.
    Please let’s not waste this opportunity. $20 billion properly spent will provide great improvements. $20 billion spent as it appears it may be spent will just raise costs and make getting to where we need to be harder.

  3. Dr. Leavitt:
    EMR is a great tool and part of the evolution of improving the collecting, storing, and retrieving of information. However, the accretion that EMR will reduce cost and improve quality of care is not the case. Reviewing several physician offices whom have implemented EMR, their costs have increased to the end customer. This is in part by design of the EMR software that is driven by questions and can easily jump a 99212 visit to a 99213 in less time than a physician spends on a traditional 99212 visit. From that standpoint EMR is a great revenue increasing tool and not a cost savings tool.
    The next item is quality. The health care industry has not defined quality and until it does, it will be irresponsible to think that EMR will help in that area. The $20B investment will be an investment to insure that the trend in higher healthcare expenditures will continue in the U.S. The U.S. has already proved that spending more money is not the solution to healthcare quality or access. I believe it would be better to spend some money on determining what basic healthcare should involve before we try to overhaul a systems that has many systemic problems. In reference to you “Code Blue” statement, the U.S. healthcare system has been there for some time and I think its time to pull the plug and start over.

  4. Mr. Leavitt…many of the BENEFITS you point out in the adoption of EMR, including the efforts of CCHIT to help bring standards to the fray, are still just POTENTIAL. With the EMR adoption rate still suffering better than 50% failures and the successful usage set at under 17% for even partial usage across the US (by the recent NEJM study)how can we say this is a good thing? Put another way, there is no reason to believe the SAME products will have any better success rate going forward…and that would mean that potentially $10 Billion or more of the proposed government investment would be wasted in failed efforts.
    All vendors should be embarrassed at this. Why shouldn’t the standard of success be practices having VERY high success rate—approaching 100%, not 100% compliance with CCHIT standards, which as can be seen from those responders below, has many criticisms, biases and objections. We need to help physicians and their practices provide better, cost-effective healthcare and spend needed time with patients, not try to make data-entry clerks out of them and force them into a volume model, rather than a quality model.

  5. All this talk about the EMR/PHR/EHR is ignoring one important aspect…the need for all this connectvitiy to actually help a patient overcome his or her barriers to action…barriers to healthy behaviors.. that absence of which contribute a great deal (some estimate 40%) of the cause of morbidity and mortality in the US. Modern technology has a key role in making this happen if and only if organized medicine provides patients with the day-to-day support they need to prevent disease and to self-manage their conditions if they are ill.
    In the connected era that means just in time delivery of the personalized and up-to-date data and information a person needs to have the knowledge and skills to make wise choices.
    It means supporting patients to easily and accurately keep track of their performance and use that knowledge to plan and implement new approaches to reaching their goals.
    It means providing tailored messages and experience that speak to each person based on their unique characteristics, their performance on key behaviors and their needs at that moment in time.
    It means helping patients link directly to family and friends for critical support, and link to their many providers to help integrate medical care with everyday life.

  6. Thanks for the compliment BevMD. I wish I could have proof read that before posting.
    WHat I find missing here in IT discussions OF EMR is what does this mean to the patient, the MD and the person who has to pay for it? In other words, you need to show concrete examples of where time and money is spent and what is the increase in quality which can then be measured as value.
    Let me give you an example of what I would find to be a simple task that a well crafted EMR system would do which would save hundreds of millions of dollars.
    Blood tests are ordered and intantly the type of tests are shown and the MD can review this with the patient and tell them that they need to fast or not fast, do it in the office or at a place like Quest. The pt does not have to know what a smac 24 is and can log in to Quest to schedule when to have the test at their convience.
    At Quest’s end, the insurance is verified and the pt can log off since Quest has the script, CLEARLY printed with orders and has all of the biling info easy to be submitted after the pt checks out. Quest now knows the pt volume, the supplies needed for ordering, the staff neeeded, the gross revenue and how to make their business more efficient.
    The blood results are sent electronically to the MD office and loaded into the pt chart. If something is very, very amiss, an email can be sent to the office, or a robo call or even a flashing warning could be made to appear on an electronic tablet the MD has which stores the pt records. The MD has a tablet with voice dictation built in so it can be immediatley placed into that pts chart. There is no need for a fax to be scooped up by a ten dollar an hour staffer in the MD office who then has to find a physical chart to place it in for the MD to eventually see when they have time. The MD and office has on a main screen a list of outstanding lab and testing and whether they results are in or not.
    Suppose that the Pt returns and the MD has to now send the staffers to find the pts chart which can be anywhere in a large office. The fax results are still in the Med records room. Now the MD has to call his nurse or MA to ask the Med records staff to find the fax and then return it. Each step costs money and eats away at the amount of time the MD has with that pt. What most MDs wil do is to just move on to the next pt and then try to remember to return and have that pts history and problems reappear in his or her memory. Well, the MD’s office should know if the pts results are in, and the records of the pt should be able to contact the provider and electronically ask for the results to be resent without sending a 10 dollar an hour staffer, and that is cheap, to spend 15 minutes, or 3 dollars in wages and benefits to make a phone call to find out the story and then wait.
    Do this a few times a day for a week and mulitply it by tens of thousands of office visits and you see how just one simple request for a test result costs a lot of money over all.
    A new pt who shows up at a new MD office with one swipe and E signature has the entire file from the old MD sent to their new MD. This makes the first visit more productive as continuation of care is very important. There is no need for the other office to send their staffers to hunt for the paper charts, make crappy copies of crappy faxes and then charge the pt up to a dollar a page for their own results.
    If the MD sends the pt to an ortho office for a kneee for example, that office will not book or continue until insurance is verified like a debit or credit card and then the records needed or images can then be requested without the patient having to go hunt for them at three different imaging offices or hospitals. Suppose the pt had a fall out of town with a fx? Ever try to get records or images sent via mail for comparison?
    Do you know how many pts show up to an ortho office and were not told that they needed films? The ortho office then tells the pt to either reschedule or in most cases, do another set of films in their office which are then billed to Medicare or insurance. Multiply that by several thousand events and see how much time and mnoney is wasted.
    The cash cost is not the only factor a pt will need to decide where to go. Many need transportation and that option should pop up and be scheduled. Perhaps a map and instructions should then pop up for a pt when they make an appt. I have used MSN maps and their sat view feature to see where the office is and where to park for a new MD or provider visit.
    For an MD, they should be able to run an office at their speed and if needed, with bare bones overhead. There is room for concierge service, however, I can see a private MD being able to offer a version of that level of service by themselves if several tasks would be replaced with a smooth operating system.
    Instad of a massive US version, we can do this in a state to see how it works with the various insureres and facilities in a continual refinement of the product. Mass would be a good place to see how this works within their health care system.
    If you look at products like a minivan or an Ipod, the engineers worked within the requirements of the consumer who was the one to be satisfied. If you can’t sell the product becuase the consumer can not use it and it does not benefit them, then you are going to blow a few billion .
    Simple design, simple use, simple money spent, simple improvements over time saving simple cents and dollars around the clock makes a winner in almost any category of product invention and marketing.

  7. Honestly, it is amazing the energy, passion and creativity that happens when you dangle 20 billion dollars in front of people. There is more then enough for vendors, groups that support them, providers, Health 2.0 consultants, insurance companies, government agencies (where are the patients in all of this)to benefit.
    It HIT the new surrogate for Rep vs Dem? Free market vs Government intervention? Perhaps there is a new collaborative hybrid model that brings vendors, supplies, and customers all to the same table? Something akin to the government, NGO and private sector response to Tsunamis? There is more then enough room for everyone to contribute to this somewhat chaotic transformation of our health care system but in our attempt to defend our own turf, people sometimes lose sight of the goal. High Quality, affordable, effective, patient centered care.
    People do what we pay them to do and we can’t fault the vendors for catering to their actual customers (Hospitals mostly)and interoperability is a real issue that the private sector has failed to resolve on its own. Once the “Payers” (employers and the federal government not necessarily consumers)start to drive this process issues of interoperability will become a competitive advantage not a requirement.
    There is a reason that closed systems like the VA and Kaiser were the first to adopt EMRs? Because the savings from implementing the systems stay in house. We know that they have better outcomes and the VA wins nearly every quality award possible for far less cost. Why then can’t Kaiser provide care for less then their competition.
    Did banks have to mandate and become certified in order to exchange banking data? Clearly there is a role for an intermediary but the problem lies in the way we pay for health care and not in the people who respond to those needs (vendors and certification agencies).
    Hospitals actually have a vested interest in preventing patients from going to their competition (unless they are uninsured) and frankly some of their profits are based on redundant unnecessary tests. We can’t expect them nor the vendors to drive this process for interoperability out of the good of the public. In Palo Alto all of the major hospital systems have the same CCHIT certified vendor (Epic). But Google employees who get their care from Kaiser or PAMG have to print their charts out and carry paper copies to see specialists at Stanford.
    If it was a pure technology challenge of interoperability we would just roll the VA system out to every public health clinic in the country and use an ASP model to deliver it to small group practices. Alas there is no “company” with a profit driven mentality to advocate for this despite its low cost and clearly demonstrated value. In fact private sector vendors are now carving out parts of it. (cerner in the lab)
    The benefits of HIT also accrue to insurance firms not to the doctors or hospitals that pay to invest in them so we need to link payment reform to HIT investments as well.
    We know for example the value of the medical home model and HIT could be extremely valuable in this high cost population but current payment systems don’t reward primary care doc’s coordinating care.
    I doubt that very many people believe that health care should remain paper based or even oppose investing in health care IT but as Dr Levitt stated it is just a tool. It is simply part of the lean process improvement that many larger systems are under-taking. The benchmark for implementing should be that it saves providers x hours minimum a week, cuts costs by X% of improves quality. Start with labs, imaging and RX but remember that 95% of all health “care” happens at home by the choices that people make on their own. Information alone never really changes behavior (look at smoking). You have to transform data to information, then to knowledge and finally to behavior change. It is that last step that is where you save costs, improve quality and create genuine change.
    Workflow redesign and payment reform are the real driver not the technology itself. In the EU there are free market models (France for example) that have nationwide HIT systems but other countries that don’t and yet they all have far higher quality then the US. The difference isn’t the technology alone.
    As we move towards Health Information Liquidity the focus should be on a much wider eco-system of communication and information flow versus ERM’s or PHR’s per se and it is exciting to see vendors, health 2.0 advocates, government, employers, non-profits (and a few consumers) to the same design table.

  8. If the goal is to promote EMR adoption, we must have a certification process. Until the certification process has more relevance to the majority of patients and the doctors deserving of their trust, our efforts will continue to falter. The majority of patients receive care from physicians in small practices. The CCHIT 100% required functionalities should be limited to a subset of the current requirements, and should only be those that are relevant to small practices. The 100% pass functions should simply pass a review by clinical representatives that are active in the small practice setting. The remaining functionalities should be moved to a category or extension dealing with enterprises, etc. The key to success is to bring real value to patients and their physicians. The value can only be defined by them and not a team of persons whose perspectives involve more integrated systems that have IT departments. It does not matter how well-intended the decision makers are if they lack a relevant perspective.
    A prime example of difference in perspective is the interoperability issue. Few doubt the value this brings. Rarely does a day pass that I do not directly speak to a physician in a small practice that has a “certified” systems that does not voice frustration by their lack of connectivity and interoperability. The physician that does not want more connectivity is the exception rather than the rule. The problem of lack of connectivity is almost always due to obstacles that remain to be addressed. For example, around the year 2000, a survey of the AAFP membership revealed that the costs for a simple HL7 interface averaged $14,000. I am confident a repeat survey in 2009 would be about the same. The lack of AFFORDABLE interoperability is an obstacle that has yet to be addressed in any meaningful fashion. The road maps to interoperability being advocated by the industry and government do not appear to offer any reasonable paths to ensure that interoperability is AFFORDABLE for a majority.
    I would love to hear of any efforts that promise to ensure that interoperability will be AFFORDABLE, even if possible.
    Best,
    Randall Oates, M.D.
    President, SOAPware, Inc.
    DOCS-Clinic and Institute, PLC

  9. Dr. Larry Weed introduced the first EMR is 1966. It was called the “Problem Oriented Medical Record” or POMS. This innovation out of the University of Vermont held great promise. Now, over 40 years later, EMR adoption is between 12-15% and even less in the small provider office setting. In our (healthcare IT) industry, ‘outcomes’ are delivered in many flavors. To the EMR industry, ‘adoption’ is equivalent to ‘outcomes’. If the consumer isn’t buying, there is a reason and any investment that rewards failure doesn’t seem to be the right answer. Although laudable in principle, certification actually paralyzes innovation. I am pleased that President Obama is willing to make investments in healthcare IT but I am not convinced that healthcare IT has come up with the right answer into which we should channel those investment dollars. Investment should be made into technologies and projects that will innovate not promulgate the status quo. As an industry, we need to be more transparent, collaborative, and relevant and we need to encourage investment that will support these objectives.

  10. Practitioners in the new medical-business are geared toward routine, discipline and profit, not innovation. Should large amounts of taxpayer money be lavished on the medical profession, patients need to be in a supervising capacity. Otherwise, taxpayers will donate to the cause only to have doctors respond, “Patient! What patient? I’ve already done you an immense favor modernizing my billing system and communicating with colleagues on your behalf, and you want MORE?”
    The author needs to check out e-patients.net, particularly their White Paper. Your assumptions about innovation and proactivity, while well intentioned, are flawed and out of date.
    – Oliver

  11. Dr. Leavitt, as I wrote in my first comment, your statements continue to be MISLEADING. I would expect more precision in use of words from someone in your position.
    A main heading in your post is: “Health IT Products are Ready Right Now”
    I suggested that today’s EHRs are not interoperable. Your response is that interoperability is not all or nothing. Agreed.
    Your comeback is that “Today’s certified office EHRs can receive lab reports electronically, and do electronic prescribing”.
    Again, this MISLEADING statement does not support your conclusion that “Health IT Products Are Ready Right Now” and that “We rigorously check not just what the software can do, but also for interoperability”.
    Are you suggesting that receiving lab data and doing ePrescribing qualifies as being “interoperable”? (You used the word first, not me). Are you also suggesting these capabilities alone support your claim that “Health IT Products Are Ready Right Now”?
    One step further. You note: “They can also import and export clinical summaries, which makes them ready for when the means of transport — health information networks — becomes available.”
    Again, this is MISLEADING.
    HL7 is the technical standard specified for transporing clinical summaries in CCHIT certified products. While HL7 v3 will be able to transmit computable clinical summaries, HL7 v2 — the prevalent standard today — transports only summary documents, not computable data. And of course you know that v2 and v3 are not compatible, so migration from v2 to v3 will be a long process.
    Again, to suggest that EHRs can “import and export clinical summaries” is just plain MISLEADING.
    Brian Klepper characterized your post as “incredible”. I’ve been using the work MISLEADING, but your continued lack of precision draws me much closer to just saying “bullshit”.

  12. PKinSFLA has many, many excellent and practical suggestions. In fact, better than most “expert” posts about health IT that I have seen on this blog. The devil is in the details and this commenter understands the details. I suggest, PKinSFLA, that you send your comment to Mr. Daschle et al because truly, many of these people have no idea what’s really needed. One used to be able to enter a suggestion at change.gov; I believe that URL will guide you to his new website, which is something like whitehouse.gov.

  13. Dr. Leavitt,
    I have no objections to a certifying body for EHRs. However, I do have the following issues with the current modus operandi of CCHIT:
    1) There should be no vendor involvement in the certification process in any capacity even if there are other experts involved and the large vendors are a minority. This will preserve some appearance of fair play.
    2) The cost of certification should be drastically reduced, so it is not prohibitive to smaller vendors, who may very well be the only road to innovation.
    3) The feature lists for certification should be reduced to a bare minimum of a few dozen items. The hundreds and hundreds of features required today are, at best, irrelevant to many physicians, and most often a hindrance. If you were certifying cars for use on US highways, you would not be requiring sunroofs, GPS, built in coolers and bicycle racks on each one, yet that is what CCHIT is doing today for EHRs. This is in effect increasing the price of the product and keeping adoption rates low, not mention the lack of usability (think about the car analogy…)
    4) Remove the 100% needed to pass. If the car has no bicycle rack, maybe I still want to buy it, because it’s more affordable and because I personally think that the bike racks are ugly.
    5) Reconsider the HIE transaction certifications. Today a vendor would have to spend $40,000 to certify its ability to exchange information with labs and pharmacies. Why? Labs make you certify anyway before they will conduct any business with you and so is SureScripts. Both for free. What value is the CCHIT certification adding for the customer?
    6) My personal suggestion would be that CCHIT concentrates on certifying standards of communication and terminologies, so EHRs and diagnostics service providers and any other clinical\financial vendor can truly communicate. The software vendors will comply if strong standards are defined. Just look at XML and HL7 and X12. This is what we need today, this and a standard terminology, because interoperability is just vaporware if every piece of software out there speaks a different language.
    7) Finally, my biggest problem is not CCHIT per se. It is the fact that CMS and the current administration are contemplating basing stimulus packages and incentives on CCHIT certification. All that will accomplish is to perpetuate the current state of affairs in the EHR market, unless, of course, CCHIT undergoes some miraculous transformation along the lines mentioned above….

  14. I’m glad my post has stimulated so much discussion and I appreciate the questions.
    Peter and rbar advocate that health reform should come before EHR adoption, not after. I agree — we mustn’t adopt EHRs, then neglect health reform. But how can we reform our health care spending if we don’t know the quality and effectiveness of what we’re buying, and how could we know those things while the source of information is scribbles on paper?
    Vince Kuraitis, mgastl, and Brian Klepper appear to feel that interoperability is an all or nothing attribute: it’s either perfect, or its worthless. But technologies should be adopted based on their value to us, not on whether they have achieved perfection. Today’s certified office EHRs can receive lab reports electronically, and do electronic prescribing — those two representing the the highest volume transactions in the typical physicians office. And that information is structured and goes directly into the appropriate fields. They can also import and export clinical summaries, which makes them ready for when the means of transport — health information networks — becomes available.
    Brian Klepper and mgastl (and others on THCB in the past) have posted some incorrect information about CCHIT which I think should be corrected, especially out of respect for the hard work of hundreds of volunteers who have contributed to CCHIT with the expectation that they are working for the common good.
    CCHIT received seed funding from AHIMA, HIMSS, and NAHIT, and several other organizations to get started in 2004. After being awarded a Federal contract, CCHIT moved to become fully independent, which it did on January 2007. It is a nonprofit, 501c3 organization with a public mission. As such, it does not generate “profit” and has never paid the founding organizations any monetary return. Regarding the influence of vendors at CCHIT, we monitor the composition of the Board of Trustees, the Commission, and all Workgroups to maintain multi-stakeholder balance. Many valuable volunteers have come from vendors, but they are not a majority on our workgroups. The drive to make certification more rigorous comes mainly from healthcare providers on our panels, not vendors.
    Regarding your questions about my own status, you may have simply found an out-of-date resume on the web. I am employed full-time by CCHIT, am no longer am employee of HIMSS, and have no financial relationships with any health IT vendors.

  15. Dr. Leavitt:
    As Vince Kuraitis and other commenters point out, your claims that the CCHIT certification process produces interoperability in the EHRs currently on the market is patently false. Send a record from, say, a Centricity (GE) system to an Allscripts system and the information doesn’t flow through from the fields in one to those in the other. That means they’re NOT interoperable. And it also means that if we spent immense dollars buying these tools for physicians, we won’t have improved the lack of communications among them very much.
    Your post waves the banner for the industry, which is all well and good, but let’s be clear here. You’ve been running a quasi-governmental organization. If I’m not mistaken, in your present position you’re on loan from HIMSS, the health IT industry association, and you’ve misrepresented the actual status of the EHRs to advocate for an allocation that would be a windfall for that sector.
    Further, many far more dis-interested organizations – meaning those that would not stand to benefit from the allocation – ranging from the Congressional Budget Office to the National Research Council have recently taken issue with your position, arguing that the goal should be outcomes, not the implementation of certain technology tools, and that there are other HIT solutions that might, over the short term, provide greater impact and value than EHRs as they are currently constituted.
    The facts that you may have a significant conflict of interest and that your information is, at best, misleading, are worrisome. The fact that you would push this sales pitch on a forum widely read by very knowledgeable colleagues is, well, incredible.

  16. I agree with ‘concerned’ and furthermore
    1) CCHIT was formed by large vendors. Its boards and workgroups contain many representatives from the large EMR vendor community. So what are they doing? Certifying themselves?
    2) EMR’s from large vendor are extremely expensive and notoriously difficult to use. This is not reflected anywhere in the CCHIT certification process. Quite the opposite, in order to become CCHIT certified an EMR must become as clunky and bloated as the older EMRs.
    3) CCHIT’s list of “must have” features looks to me like the specifications of any given large EMR vendor, including all sorts of useless features that just happen to be there. I wonder what was the basis for these requirements….
    4) CCHIT is now making vendors pay to certify for transactions that they are currently performing anyway with commercial labs, for example. Why does an EMR that is obviously communicating rather well with labs already, need to pay CCHIT to test and certify that fact?
    5) There is no EMR-to-EMR interoperability testing. I wonder what that would look like though. Probably require all other EMR’s to work with the vendors that founded and still run CCHIT.
    6) Every year, the cost to become CCHIT certified increases since CCHIT is certifying more and more granular pieces of an EMR. When once there was an Ambulatory certification, now there is that, plus child care, cardiovascular, electronic prescribing, etc. Each one of these has an additional cost. Very clever way to extract more money from vendors.
    7) CCHIT today is becoming a barrier for new innovative small companies to enter the EMR market, thus preserving the market share of the old clunky, overpriced vendors. This certification is in effect a barrier to free market competition.
    Is that what this new administration really wants to do? Is this really the road to all the wonderful things that investment in HIT is supposed to bring? We need change …..

  17. My thinking is that a massive scale of change will give us a massive headache and we should take a lesson in “First, do no harm”. The other lesson is from Edward Demmings in looking for incremental improvements in quality to lower flaws and increase effeciency.
    In the filed of Xray where I am employed, electronic records of Xrays were talked about in my first class in 1993. It took 7 years to see digital Xray to be offered for sale and another year or so for PACS Picture Archival Computer Storage to be installed.
    That time period was not wasted as the many manufacturers and health organisations had ot agree on a standard language called DICOM which would form the standard computer language. It then took breakthroughs in computer speed and above all lower memory and sotrage prices to speed th eprocess up. Finally, the vendors of software and the manufacturers of equipment had to design and price new equipment so it was affordable.
    Giving a blank check would not have brought this about, but made people handing out the checks feel good.
    The savings in digital Xray and transformation wiped out the old fasioned film and developer business, but created a whole new industry. Those companies which were on the ball made the transformation.
    The most important savings in my opnion is in how does this make life easier for the patient, then the MD, then the support staff.
    Savings are not just calculated in dollars , but in time. Here is what I have seen change in digital X-ray, including CT, MRI and other studies which can have images be reduced to pixels which are reduced to 1s and 0s.
    -Patients can get their studies in a few minutes on a CD or DVD instead of waiting for the images to be developed, loaded on a view box, read by the Rad, dictated, transcribed and in a few days released to them. With voice recogniton software, the Rad can dictate a stored image while the patient is long gone to another specialist with his or her images.
    -The staffs of the hospital can do more work with the same people and not waste time with lost films.
    -I can take more images with less repeats and improve the quality and work closer with patients instead of spending time in dark rooms inhaling chemicals. I can see more patients who spend less time waiting and being in my exam room.
    -We do not need a darkroom, hazardous waste and chemicals and hundreds of boxes of film each year.
    -The Rads and MDs are able to manipulate images with software which blows away film. Once you are using digital equipment, you look back in shock when a regular film is viewed on the view box.
    -We wish to get away from using CDs and setting up a web based site for the patients MDs to view their images online. This means that the patient no longer has to even go to the other MD office with a disc as the report and images are now electronic.
    -I have a terminal in my room so I can review any scripts since we scan them in when a patient does their paper work. Some MDs have specific requests of views and I can change the order instantly as needed. This means that there are very few call backs foe the wrong test or an incomplete test which saves the patient and myself time while making billing and reading faster.
    -I have worked in many MD offices and have seen the waste of money and resources for the MD to just chuck a film on a view box for 10 seconds and then go on to somehting else. After the films are looked at, do you think that the MD will now pay 5 bucks to send it back for storage by the imaging center? Multiply that by hundreds of patients and you will see why when I worked for Humana’s madical offices they just threw the films into a big room and let them sit there for years. HWen it caem time to shut down the iffice, no one had any interest in filing, packing or shipping thousands and thousands of films back to where they came from.
    -One problem encountered is that some offices are too lazy to insert the CD which loads up automatically. They send the poor patients back to get film (for 10 dollars a sheet) so they can plop it on their view box for ten seconds and then hand it back or throw it int the store room.
    When I was working in one office it was common for lab results ot come back with most of the tests done except for those which took longer. What happens when they send in a report with the first results? The staff, which is often busy chasing mountains of paper considers that to be the final results and files them with the patient chart. The MD goes to their office and attacks a pile of charts and may not remember all of the blood work ordered. Some tests may get lost or not make the fax and then are never placed on the chart until a few weeks go by and the patient calls us asking about it.
    If you ever are told by a medical office that “we will call you if their are any problems with your test results” find another office. I have seen way too many test results lost in the paper shuffle. One ex employee had hundreds fo test results jammed in a cabinet that she gave up trying to find the chart for!
    What I would want to see is the ability for any test to be ordred or drug to be ordered to be electronically reviewed for insurance coverage, avalable facilities and patient data to be loaded. The computer generation could od this in either the MD office, on their PDA or I phone or in their work or home computer without having to make phone calls.
    Quest diagnostics has a nice system for making appointments whic I find to be easy to use, All I need is for my MDs to be able to automatically send the needed tests and for me to have a medical records program in my house so I can load them to keep trakc of them.
    Ultimately, what I want, since I am a patient and concsumer of health care besides an employee is real simple. When I enter an MD office ALL questions of billing and deductables are answered BEFORE I am allowed ot make the appt. This keeps you and the MD staff from wasting time arguing and calling insurance companies about coverage. The patient should just have to swipe his or her card like a debit card for just about the entire medical form to be filled in and just signed. All of my meds, doses previous exams and test results are either on the card or accessed like an ATM or debit machine.
    When I end up in a hospital, the card has a photo to make sure that I am who I am supposed to be to prevent fraud. If I am unable to repsond, my allergies and meds are instantly known along with medical conditions and things like weather I have stents, knee or hip replacements, are they MRI safe, what my normal blood work is etc. When I worked in an ER the amount of time it took to get this info was horrendous as you havbe people who are in shock or family members who do not know.
    I can think of so many other ways that the streamling and changeover to electronic medical recirds can benefit the patient and the MD. I would like to see this done in a way that a single MD could have an office with one or zero employees with such low overhead that he or she could practise as they see fit and still make some money.
    Patients would have the ability to keep track of their health the same way they use quicken to keep track of their investments. Medical offices do not lose information, do not have high overhead costs, the MD can have instant access to medical history , get paid faster and above all, the patient’s life is just a bit better and simpler.

  18. Here is my opinion on CCHIT.
    1. Vendor pays lots of money to CCHIT
    2. CCHIT performs check box review of “features”
    3. Stamp gets placed
    4. No analysis that the system is actually useable in such a way that promotes improved workflow or patient care.
    5. CCHIT stamp is less than a reliable indicator that the product is worthwhile.
    Please give me something to believe in, because at this point your stamp on 160 products is a stamp on a lot of things that haven’t met with anything that I would call a high quality of product. Not withstanding the suboptimal service offered by these vendors.

  19. The trouble is not with the EHRs or slow adoption, it’s with the processes. Spending $20 billion to shoehorn electronic medical records into physician clinics will spur a lot of adoption, but I predict it will generate more heat than light without careful attention to work-flows. The devil, here, is in the details.

  20. Your statement about the state of interoperability is MISLEADING:
    “We rigorously check not just what the software can do, but also for interoperability – the ability to share information with other providers — and the security of the systems as well, all against established standards.”
    This statement should NOT be interpreted to mean that 1) current EHRs are interoperable (they are not), or that 2) standards for interoperability are in use (adoption is minimal). CCHIT can “mandate” technical standards, but the market has to follow and actually use mandated standards.
    Please clarify in plain language what you’re trying to say here.

  21. I agree with Peter. Let’s just assume that EHR are a worthwhile investment – I believe it could be, if the implementation does not cause a major chaos over years, but the first priority should be to get more bang for the healthcare buck. EHR might be marginally to modestly helpful for that goal by reducing redundant testing, but it will not fix our intensifying healthcare woes.

  22. I remain unconvinced that Health IT is the best place to spend $20 billion dollars before we fix the underlying reasons for the coming financial collapse of healthcare. To me it’s the cart before the horse and a red herring meant to stall real reform. Taiwan instituted health smart cards for all of its citizens, a great IT innovation, but that was to support a strong foundation of government run single-pay. It’s like saying we need to provide students with computers before solving education. You will be disappointed Mike.

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